Intraepidermal Nerve Fiber Density Testing

Policy ID: L-4-014

Section: Laboratory

Effective Date: May 01, 2020

Revised Date: January 08, 2024

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Skin biopsy is used to assess the density of epidermal (intraepidermal) nerve fibers using antibodies to a marker found in peripheral nerves. This procedure is proposed as an objective measure of small fiber neuropathy by identifying a reduction in the density of nerve fibers.

Criteria

Skin biopsy with epidermal nerve fiber density measurement for the diagnosis of small-fiber neuropathy may be considered medically necessary when ALL of the following conditions are met:

Individual presents with symptoms of painful sensory neuropathy; and
There is no history of a disorder known to predispose to painful neuropathy (e.g., diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy); and
Physical examination shows no evidence of findings consistent with large-fiber neuropathy, such as reduced or absent muscle-stretch reflexes or reduced proprioception and vibration sensation; and
Electromyography and nerve-conduction studies are normal and show no evidence of large-fiber neuropathy.

Skin biopsy with epidermal nerve fiber density measurement not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

11102

11103

11104

11105

11106

11107

Measurement of sweat gland nerve fiber density is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Non-Covered Procedure Code

88356

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 New Policy

Internal Medical Policy Committee 3-17-2021 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-22-2021 Coding update:

Removing codes 88305; 88314; and 88356.

Internal Medical Policy Committee 11-23-2021

Updated with clarifying language

Internal Medical Policy Committee 7-21-2022 Revision with coding update - Effective September 05, 2022

Added Non-covered procedure code 88356

Internal Medical Policy Committee 1-16-2024 Coding update - Effective March 04, 2024

Removed procedure code 88342

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: L-4-013

Section: Laboratory

Effective Date: May 01, 2020

Revised Date: October 26, 2021

Revision Effective Date: January 03, 2022

Last Reviewed: November 23, 2021

Archived Date: September 04, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Skin biopsy with epidermal nerve fiber density measurement for the diagnosis of small-fiber neuropathy may be considered medically necessary when ALL of the following conditions are met:

Individual presents with symptoms of painful sensory neuropathy; and
There is no history of a disorder known to predispose to painful neuropathy (e.g., diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy); and
Physical examination shows no evidence of findings consistent with large-fiber neuropathy, such as reduced or absent muscle-stretch reflexes or reduced proprioception and vibration sensation; and
Electromyography and nerve-conduction studies are normal and show no evidence of large-fiber neuropathy.

Procedure Codes

11102

11103

11104

11105

11106

11107

88342

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 New Policy

Internal Medical Policy Committee 3-17-2021 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-22-2021 Coding update: Removing codes 88305, 88314 and 88356.

Internal Medical Policy Committee 11-23-2021 Updating clarifying language

Links

References (PDF)

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